Avishag LaishFarkash MD PhD Director EP and Pacing Unit Assuta Ashdod University MC BenGurion University of the Negev AF and HF the related twin epidemics of CVD AF is the most common cardiac arrhythmia ID: 774929
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Slide1
Atrial Fibrillation Ablation in Heart Failure
Avishag Laish-Farkash, MD, PhD
Director, EP and Pacing Unit,
Assuta
Ashdod University MC
Ben-Gurion University of the Negev
Slide2AF and HF – the related twin epidemics of CVD
AF is the most common cardiac arrhythmia
The lifetime risk of AF is 1:4 in individuals aged > 55Y
AF begets HF and HF begets AF
AF and HF share common pathophysiological mechanisms and underlying risk factors and independently predict each other
The prevalence of AF among HF: 10-57%
The rate of HF in patients with persistent/long standing persistent AF is 40-55%
Slide3AF and HF – the related twin epidemics of CVD- (cont.)
AF and HF synergistically confer worse outcomes compared with either condition alone
It is of paramount importance to elaborate effective and safe treatment strategies to prevent/reverse AF in HF patients
Since most conventional AAD are CI/ineffective/not well tolerated in
HFrEF
patients, catheter ablation of AF provides an increasingly important option
Slide4AF begets HF and HF begets AF
AF can promote development/progression of systolic/diastolic HF by several established mechanisms: - Loss of atrial contraction and contribution to ventricular filling- Persistent rapid ventricular contraction can impair myocardial contractility (directly or through cellular and neurohormonal modulation)- Rhythm irregularity may itself decrease CO, irrespective of ventricular rate
Santhanakrishnan
R,
Circulation 2016;133:
484–
92
Ferreira JP, Int J Mol Sci 2015;16:3133–47
Slide5AF begets HF and HF begets AF- cont.
On the other hand, ventricular dysfunction promotes atrial structural and electrical changes by several hemodynamic, mechanical and neurohormonal mechanisms:- Activation of RAAS- resulting in structural remodeling and anisotropic conduction- Volume retention, increased ventricular filling pressures and functional MR can lead to atrial stretch and fibrosis- HF-associated alternations in calcium handling and overload may contribute to arrhythmogenesis
Li D
Circulation 2001;104:2608–14
Cha YM, Circulation 2004;109:2839–43.
Slide6AF-mediated tachycardiomyopathy
AF is the most common cause of TICMP in adults
These patients gain the greatest clinical benefit from restored SR and most likely recovers normal LV systolic function
It is of paramount importance to
determine whether (or to what extent) AF contributes to ventricular dysfunction-
by an attempt to strict rhythm control for at least 6-8 weeks- documented improved LVEF would confirm the association and Dx
Slide7AF-mediated tachycardiomyopathy- (cont.)
Since not only rapid but also normal irregular ventricular response can lead to TICMP (alike frequent VPBS), pharmacologic rate control alone may not be sufficient for treating AF+HFRecent studies show that freedom of AF recurrence and absence of ventricular LGE on cMRI predict improvement of LV dysfunction after AF ablation
Prabhu S, CAMERA-MRI, JACC 2017;70:1949-61 Addison D, JAHA 2016;5:e003570 Ling L-H, Heart Rhythm 2013;10:1334–9
Slide8Lessons learned from pharmacological rhythm control
Regardless of what begets what, tackling the arrhythmia in patients with AF and
HFrEF
is key to clinical and functional improvement
Rate control or rhythm control???- a question of debate
Rhythm control by AAD is limited to amiodarone and
dofetilide
These can be associated with adverse effects and toxicity
Hence,
rhythm control may be preferred over rate control if SR maintenance can be achieved without AAD
Slide9Catheter ablation in patients with AF and HF
Slide10Randomized trial support for AF ablation in pts with HF and reduced EF
Slide11The PABA-CHF (Pulmonary Vein Antrum Isolation vs. AV Node Ablation with Bi-Ventricular Pacing for Congestive Heart Failure) trial
Showed that catheter ablation resulted in 88% AF-free survival (71% off AADs) and absolute increase in LVEF by 8% at 6 months of follow-up compared with no relevant change in LVEF (−1%) in the pace-and-ablate group (P < 0.001)Functional capacity and QOL significantly improved in patients randomized to AF ablation Limitations: relatively small number of patients (n=81), short follow-up (6 mo), and high probability of substantial selection bias
Khan MN et al. N Engl J Med 2008;359:1778–85
Slide12ARC-HF (A Randomized Trial to Assess Catheter Ablation vs. Rate-Control in the Management of Persistent Atrial Fibrillation in Chronic Heart Failure)CAMTAF (Catheter Ablation vs. Medical Treatment of Atrial Fibrillation in Heart Failure)
prospectively compared ablation-based rhythm control with pharmacological rate control in patients with persistent AF and LV dysfunctionThe two studies demonstrated >80% AF-free survival off AADs and significant increase in exercise capacity and QOL in the ablation group at 6–12 months
Jones DG et al. ARC-HF, J Am Coll Cardiol 2013 ;61:1894–1903Hunter RJ et al. CAMTAF, Circ AE 2014;7:31–38
While the ARC-HF trial reported a trend towards LVEF improvement (+11% vs. +5%;
P
=
0.055), the CAMTAF trial showed a
significant increase in LVEF
(+8% vs. −3%;
P
<
0.001) in the ablation group
Slide13CAMERA-MRI (Catheter Ablation vs. Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction) trial
(n=68) Ablation-based rhythm control (posterior box isolation) in persistent AF results in a significant improvement in LVEF and LVEF normalization ≥50% (58% vs. 9%, P = 0.0002), particularly in the absence of ventricular LGE on pre-procedural cardiac MRIIn the ablation group, the absence of LGE predicted greater improvements in LVEF and higher rates of LVEF normalization at 6 months [73% vs. 29%; mean difference 44.2% (95% CI 10.7–66.1%); P = 0.0093]
Prabhu S et al. J Am Coll Cardiol 2017;70:1949-1961
Slide14(A) Change in absolute left ventricular ejection fraction from baseline according to treatment arm (B) % Ventricular LGE status in patients who underwent AF ablation (C) Correlation between % of ventricular LGE and ΔLVEF following catheter ablation in CAMERA-AF:
Despite a relatively small cohort, this data adds a promising piece to the puzzle on how to identify and select good ablation candidates who most likely benefit from an AF ablation approach
Prabhu S et al. JACC 2017;70:1949-61
Slide15AATAC-AF (Ablation vs. Amiodaron for Treatment of Atrial Fibrillation in Patients with CHF and an Implanted ICD/CRT-D) trial
203 patients with persistent AF and HFrEF [NYHA class II–III; LVEF ≤40%] – randomized to either amiodarone or catheter ablationAt 2 years f/u: 70 % AF free survival in PVI group (± posterior wall isolation ± non-PV trigger ablation in 78%) vs. 34% in the amiodarone group (P < 0.001)Amiodarone was a predictor of arrhythmia recurrence [HR 2.5 (95% CI 1.5–4.3), P < 0.001].
Di Biase L et al. Circulation 2016 ;133:1637–1644
Slide16AATAC-AF (Cont.)
Improvement in LVEF was significantly higher in the ablation arm (8% vs. 6%, P = 0.02) and associated with freedom of AF recurrence
Di Biase L et al. Circulation 2016 ;133:1637–1644
Secondary outcomes (small numbers): catheter ablation was better than amiodarone in
reducing unscheduled hospitalization (31% vs. 57%, P < 0.001) and all-cause mortality (8% vs. 18%, P = 0.037)Conclusion: AATAC-AF proved that ablation is superior to amiodarone in terms of rhythm control and improvement in LV dysfunction
Slide17CASTLE-AF (Catheter Ablation vs. Standard Conventional Treatment in Patients with Left Ventricular Dysfunction and Atrial Fibrillation) trial
363 patients with PAF or persistent AF and HFrEF (NYHA II–IV; LVEF ≤35%), who were randomized to either catheter ablation or pharmacological Tx – 70% rate control and 30% rhytm control, predominantly amiodarone (in contrast to AATAC-AF!) f/u up to 5 years (median 37.8 months)Primary endpoint: all-cause mortality and hospitalization for worsening HF
Marrouche NF et al. N Engl J Med 2018 ;378:417-427
Slide18CASTLE-AF- results:
A significant reduction in the primary composite endpoint [28.5% vs 44.6%, HR 0.62 (95% CI 0.43-0.87), p=0.007]; NNT = 8.3There was also benefit in all-cause mortality alone [13% vs. 25%, HR 0.53 (95% CI 0.32–0.86),P=0.01], mainly driven by a significantly lower rate of CV death in the ablation arm [11% vs. 22%, HR 0.49 (95% CI 0.29–0.84), P=0.009], However, the mortality benefit of AF ablation did not emerge until after 3y
Marrouche NF et al. N Engl J Med 2018 ;378:417-427
Slide19CASTLE-AF- results (Cont.):
Catheter ablation led to a significant improvement in LVEF at 5 years vs. meds (+8.0% vs. +0.2%,P=0.005), which was essentially driven by ablation of persistent (+10% vs. -2.5%, P=0.004) and not paroxysmal AF68% of patients in the ablation group showed an increase in LVEF beyond the magical cut-off of 35% !!!
Slide20CASTLE-AF- results (Cont.):
Subgroup analysisA significant interaction between LVEF and the primary endpoint: Patients with LVEF ≥25% were more likely to benefit from AF ablation than patients with a LVEF<25%Both paroxysmal and persistent AF groups benefited from catheter ablation, but in particular ablation of persistent AF was superior to medical therapy for the primary endpoint
Slide21CASTLE-AF- results (Cont.):
Catheter ablation significantly reduced the AF burden and resulted in stable sinus rhythm in 63% of cases at 5y (vs 22% in the medical Tx group)The adjusted rate of AF recurrence (patients who had actually undergone ablation and completed the 5y f/u) (75/151) was 50%, average of 1.3±0.5 procedures/patient
Suggests that maintenance of SR is beneficial when achieved without AAD and supports the widely used approach of extensive LA ablation in persistent AF
Slide22Is one ablation strategy fits for all?
In
CASTLE-AF -
Additional LA lesions in only 53%
of all AF ablation procedures, despite the fact that 70% of patients randomized to catheter ablation had persistent or long-standing persistent AF.
This is in contrast to the other completed RCTs, in which the vast majority (78–98%) of patients with persistent AF received LA lesions in addition to PVI
The
ongoing
CONTRA-AF
trial
compares single shot
cryoballoon
ablation with pharmacological rate or rhythm control in patients with paroxysmal or persistent AF and
HFrEF
(NYHA II–IV;LVEF≤35%)
Taken all RCTs together,
it remains unanswered which AF ablation strategy
is optimal and should be recommended to achieve the reported favorable outcomes
Slide23Is one ablation strategy fits for all?- (cont.)
In patient cohorts with severe
HFrEF
, advanced structural remodeling, or non-convertible AF following PVI, additional ablation is often needed first-line
Whether empirical linear lesions, targeted non-PV trigger ablation, LA appendage isolation, ablation of complex fractionated atrial electrograms (CFAE), or substrate (low voltage) modification ensure superior success is a controversial matter of opinion, and comparison of the different ablation strategies in patients with HF lacks evidence
Slide24Proposed approach to individually tailored catheter ablation irrespective of the atrial fibrillation type and underlying heart disease (based on voltage mapping and inducibility of atrial arrhythmias)
Richter S, Di
Biase L and Hindricks G, EHJ 2019;40:663-72
*May be considered in cases of non-convertible AF after PVI or patients with persistent/long-standing persistent AF
Slide25Complications related to AF ablation in HFrEF
Richter S, Di
Biase L and Hindricks G, EHJ 2019;40:663-72
Slide26Ongoing large randomized controlled trials on AF ablation in patients with HFrEF
Slide27Current guideline recommendations on AF ablation in patients with HF
Kirchhof P et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016;37:2893–2962
Slide28Current guideline recommendations on AF ablation in patients with HF (cont.)
Calkins H, Hindricks G, Cappato R, et al. 2017 HRS/EHRA/ECAS/APHRS/ SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation Europace 2018;20:e1–e160
Slide29Current guideline recommendations on AF ablation in patients with HF (cont.)- Pace and ablate
Brignole M et al. EHJ 2018; 39(45): 3999-4008
-There is a legitimate role for AV junctional ablation with resynchronization therapy. In particular, elderly patients with HFrEF (LVEF ≤45%) and symptomatic persistent AF with uncontrolled ventricular rates, who are unsuitable candidates for AF ablation or had previously failed ablation attempt(s), should be considered for a biventricular pace-and-ablate strategy (Class IIa-B)-The most recent APAF-CRT trial demonstrated a prognostic benefit of biventricular pace-and-ablate over pharmacological rate control also for patients with HFrEF and narrow QRS complex (QRS ≤110ms)
Slide30Current guideline recommendations on AF ablation in patients with HF (cont.)
Kirchhof
P,
2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
Eur Heart J 2016;37:2893–2962
Slide31Proposed rhythm management strategy in patients with AF and HF based on recent evidence and current guideline recommendations
-Richter S, EHJ 2019; 40:663-72 -Prabhu S, CAMERA-MRI, JACC 2017;70:1949-61-Di-Biase L, AATAC study, Circulation 2016; 133: 1637-44 -Marrouche NF, NEJM 2018; 378:417-27
Slide32Considerations for appropriate patient selection for AF ablation in HF and reduced EF
There is no clear consensus on appropriate patient selection for catheter ablation or optimal ablation strategy in this settingIn the RCTs, there was a distinct selection bias towards younger and less severely affected patients with low(er) peri-procedural risk profileThus, careful patient selection for AF ablation is key important to achieve similar outcome benefits and should currently be geared to those HF populations included in previous RCTs
Key clinical characteristics of the HF patients randomized to AF ablation in the 3 recent RCTs
Slide33Clinical guidance to the choice of treatment in patients with AF and HFrEF
Richter S, Di Biase L and Hindricks G, EHJ 2019;40:663-72
Slide34Treatment choices following rhythm control failure in patients with HFrEF
No evidence-based recommendation;
The management of patients with
HFrEF
and recurrent AF (>3 months) after an initial ablation procedure should be individually tailored
based on previous clinical outcome, updated risk benefit
assessment, and patient choice (
AF Heart Team
)
Options:
Slide35Treatment choices following rhythm control failure in patients with HFrEF
No evidence-based recommendation;
The management of patients with
HFrEF
and recurrent AF (>3 months) after an initial ablation procedure should be individually tailored
based on previous clinical outcome, updated risk benefit
assessment, and patient choice (
AF Heart Team
)
Options:
Hybrid
rhythm control strategy
- possible synergistic effects on different AF drivers and
substrates. It
may be considered when either therapy alone has previously been ineffective (Class
IIa
-C) or higher risk of recurrence (including persistent AF+HF); A weak evidence in support of first line strategy (Class IIb-C)
Slide36Treatment choices following rhythm control failure in patients with HFrEF
No evidence-based recommendation;
The management of patients with
HFrEF
and recurrent AF (>3 months) after an initial ablation procedure should be individually tailored
based on previous clinical outcome, updated risk benefit
assessment, and patient choice (
AF Heart Team
)
Options:
Hybrid
rhythm control strategy
- possible synergistic effects on different AF drivers and
substrates. It
may be considered when either therapy alone has previously been ineffective (Class
IIa
-C) or higher risk of recurrence (including persistent AF+HF); A weak evidence in support of first line strategy (Class IIb-C)
A repeat ablation procedure
-
patients with previous clinical benefit from ablation or with failure/contraindication of amiodarone
Slide37Treatment choices following rhythm control failure in patients with HFrEF
No evidence-based recommendation;
The management of patients with
HFrEF
and recurrent AF (>3 months) after an initial ablation procedure should be individually tailored
based on previous clinical outcome, updated risk benefit
assessment, and patient choice (
AF Heart Team
)
Options:
Hybrid
rhythm control strategy
- possible synergistic effects on different AF drivers and
substrates. It
may be considered when either therapy alone has previously been ineffective (Class
IIa
-C) or higher risk of recurrence (including persistent AF+HF); A weak evidence in support of first line strategy (Class IIb-C)
A repeat ablation procedure
-
patients with previous clinical benefit from ablation or with failure/contraindication of amiodarone
Biventricular
pace-and-ablate strategy
(Class
IIa
-B)
Slide38Treatment choices following rhythm control failure in patients with HFrEF
No evidence-based recommendation;
The management of patients with
HFrEF
and recurrent AF (>3 months) after an initial ablation procedure should be individually tailored
based on previous clinical outcome, updated risk benefit
assessment, and patient choice (
AF Heart Team
)
Options:
Hybrid
rhythm control strategy
- possible synergistic effects on different AF drivers and
substrates. It
may be considered when either therapy alone has previously been ineffective (Class
IIa
-C) or higher risk of recurrence (including persistent AF+HF); A weak evidence in support of first line strategy (Class IIb-C)
A repeat ablation procedure
-
patients with previous clinical benefit from ablation or with failure/contraindication of amiodarone
Biventricular
pace-and-ablate strategy
(Class
IIa
-B)
Surgical ablation
- in case of an established indication for conventional cardiac surgery
(Class
IIa
-A)
Slide39Conclusions and future directions
Slide40Catheter ablation provides the superior approach to rhythm and symptom control compared with drug therapy and results in significant clinical and functional improvements
Slide41Catheter ablation provides the superior approach to rhythm and symptom control compared with drug therapy and results in significant clinical and functional improvements
AATAC-AF and CASTLE-AF trials indicate also
improvement
in prognostic surrogates for HF outcomes (including hospitalization for
worsening HF and mortality)
Slide42Catheter ablation provides the superior approach to rhythm and symptom control compared with drug therapy and results in significant clinical and functional improvements
AATAC-AF and CASTLE-AF trials indicate also
improvement
in prognostic surrogates for HF outcomes (including hospitalization for
worsening HF and mortality)
3) Catheter ablation can safely be performed with acceptable
complication rates in patients with HF
Slide43Catheter ablation provides the superior approach to rhythm and symptom control compared with drug therapy and results in significant clinical and functional improvements AATAC-AF and CASTLE-AF trials indicate also improvement in prognostic surrogates for HF outcomes (including hospitalization for worsening HF and mortality)3) Catheter ablation can safely be performed with acceptable complication rates in patients with HF4) However, long-term success rates of single and repeat ablation for non-paroxysmal AF seem to be lower in patients with than without HF (*)
*) Cha YM, Circ AE 2011;4:724-32
*) Ullah W, Europace 2016;18:679-86
Slide44Catheter ablation provides the superior approach to rhythm and symptom control compared with drug therapy and results in significant clinical and functional improvements AATAC-AF and CASTLE-AF trials indicate also improvement in prognostic surrogates for HF outcomes (including hospitalization for worsening HF and mortality)3) Catheter ablation can safely be performed with acceptable complication rates in patients with HF 4) However, long-term success rates of single and repeat ablation for non-paroxysmal AF seem to be lower in patients with than without HF (*) 5) Controversies still exist in how to ablate patients with persistent and long-standing persistent AF, who frequently present with advanced forms of fibrotic atrial cardiomyopathy
*) Cha YM, Circ AE 2011;4:724-32
*) Ullah W, Europace 2016;18:679-86
Slide45Future directions:1) Sophisticated strategies for electrophysiological substrate visualization and modification to improve ablation outcome, with development towards an individualized patient-tailored approach
Kottkamp H, JACC 2015;65:196–206
Slide46Future directions:2) Advanced AF-trigger and substrate modification concepts should target precise localization and ablation of areas thought to be crucial for arrhythmia initiation and perpetuation (3D-EAM; focal impulse and rotor modulation techniques; but also pre-ablation MRI-derived LGE plays an increasing role in atrial tissue characterization and localization of atrial fibrosis)
Oakes RS, Circulation 2009;119:1758–1767
Slide47Future directions:3) Image integration of electroanatomical (CFAE; low voltage) and structural (fibrosis) information fused on 3D anatomical MRI models of the atria
Marrouche NF, the DECAAF study. JAMA 2014; 311:498–506
Slide48Real-time MRI -may possibly enable non-fluoroscopic MRI-guided catheter ablation of the patient’s individual AF substrate Moreover, concomitant pre-ablation MRI screening for ventricular LGE has proven very useful to identify and select appropriate ablation candidates with HF who most likely benefit from an AF ablation approach (*)Finding new markers and tools for risk/benefit assessment and patient selection for catheter ablation should be another step forward in the treatment of AF in patients with HF
*) Addison D, J Am Heart Assoc 2016;5:e003570
*) Prabhu S, CAMERA-MRI study. JACC 2017;70: 1949–1961
Slide49Thank you!
avishagl@assuta.co.il
“The exciting journey of AF catheter ablation in HF has
already begun and it looks that we are getting far beyond the
first step…”
(S. Richter)
Slide50AF and HFpEF likewise share common mechanisms and risk factors and jointly confer an adverse prognosisAF occurs in >50% of patients with HFpEFNew-onset AF is prevalent in HFpEF and is associated with an increased mortality (HR 1.83 [95% CI 1.41 to 2.37], P<0.0001) Maintenance of normal sinus rhythm and AV synchrony is key to improve diastolic function and clinical outcome in patients with HFpEF
AF ablation in patients with HF and preserved LV systolic function (
HFpEF
)
Slide51There is scarce evidence for AF ablation in this HF populationA small single-center study suggests that AF catheter ablation in patients with HFpEF frequently requires repeat and more extensive ablation (>60%) and concomitant AADs to achieve effective rhythm control. Successful maintenance of sinus rhythm was associated with improvement in diastolic function
AF ablation in patients with HF and preserved LV systolic function (HFpEF) (cont.)
Machino-Ohtsuka T, JACC 2013;62:1857-65
Slide52These findings were expanded by a retrospective study comparing the outcomes of AF ablation in patients with HFpEF and HFrEF: AF ablation was equally safe and effective in HFpEF and HFrEFArrhythmia-free survival at 12 months was 66% in HFpEF and 67% in HFrEF, with only 6% and 3% repeat ablation, respectively. Approximately 50% of patients with HFpEF and HFrEF received concomitant AADs Additional LA lesions were frequently required and equally often performed in both groupsRates of arrhythmia recurrence at 12 months remained similar between groups in patients with paroxysmal and persistent AF
AF ablation in patients with HF and preserved LV systolic function (HFpEF) (cont.)
Black-Maier E, Heart Rhythm 2018;15:651-7
Slide53Effective treatment directed toward hypertension and LV diastolic dysfunction is an important adjunct to the ablation approach in achieving long-term rhythm control and preventing atrial remodeling progression (*)
AF ablation in patients with HF and preserved LV systolic function (HFpEF) (cont.)
*) Pathak RK, ARREST-AF study, JACC 2014;64:2222-31**)Cha YM, Circ AE 2011;4:724-732
- In a prior study from the Mayo Clinic including 157 patients with diastolic dysfunction,
1-year AF-free survival after catheter ablation
in patients with
HFpEF
was excellent (75% off and 85% on AADs) and compared well to that in patients with normal LV function (**)
-However,
5-year freedom from AF recurrence
was 29% off and 40% on AADs as compared to 46% and 65%, respectively, in control patients without HF (**)
Slide54There is an urgent need for RCTs on AF ablation in HFpEF. The upcoming EVENT-AF (Catheter Ablation for Atrial Fibrillation in Heart Failure with Preserved Ejection Fraction) trial, which is designed to assess the effect of catheter ablation on the primary outcome of HF hospitalization or mortality in patients with HFpEF, will provide further evidence on the efficacy and prognostic value of ablation-based rhythm control in this particular HF patient population
AF ablation in patients with HF and preserved LV systolic function (
HFpEF
) (cont.)
Slide55Rationale for rhythm control in
patients with AF and HF
Slide56Lessons learned from pharmacological rhythm control
Regardless of what begets what, tackling the arrhythmia in patients with AF and
HFrEF
is key to clinical and functional improvement
Rate control or rhythm control???- a question of debate
Rhythm control by AAD is limited to amiodarone and
dofetilide
. These can be associated with adverse effects and toxicity
Slide57Lessons learned from pharmacological rhythm control (cont.)
The AF-CHF trial showed no differences in all-cause mortality and worsening HF between pharmacological rate and AAD-facilitated rhythm control (amiodarone + DCCV)
Roy D, NEJM 2008;358:2667-77
Slide58Lessons learned from pharmacological rhythm control- (cont.)
In the DIAMOND-CHF trial: dofetilide had no effect on all cause mortality (but increased probability of SR)In contrast, restoration and maintenance of SR was associated with significant reduction in hospitalization and mortality Hence, rhythm control may be preferred over rate control if SR maintenance can be achieved without AAD
Pedersen OD, Danish Investigators of Arrhythmia and Mortality on Dofetilide in CHF, Circulation 2001;104:292-6
Slide59Catheter ablation for non-pharmacological rhythm and symptom control
Catheter ablation (CA) is currently recommended in patients with PAF (class I-A) and persistent AF (class IIa-B) who remain symptomatic despite adequate attempts of meds (rate or rhythm control)Emerging evidence shows that also first-line CA is more effective than AAD in achieving rhythm and symptom control, especially in younger pts with recurrent PAF (IIa-B) or persistent AF (IIa-C) and low-risk profile for procedure-related complications
Kirchhof P et al, 2016 ESC guidelines for the management of AF, EHJ 2016;37:2893-62
Slide60Catheter ablation for non-pharmacological rhythm and symptom control- (cont.)
Moreover, observational and non-randomized studies (including recent data from the Swedish AF Registry) even suggest that CA may be associated with lower risk of stroke and reduced morbidity and mortality
Friberg L, EHJ 2016;37:2478-87
Slide61CABANA trial:2204 pts with new-onset or untreated AF were randomly assigned to either CA or drug TxFailed to demonstrate that CA is superior to drug Tx for primary outcome (composite of all-cause mortality, disabling stroke, serious bleeding, cardiac arrest) at 5y based on conventional ITT analysis
Packer DL, CABANA trial, JAMA 2019, 321(13);1261-74
Slide62CABANA trial:However, there was a highly significant reduction in primary and secondary (all-cause mortality; death or CV hospitalization) outcomes with CA based on an as-treated analysis, which has additionally been performed owing to the high cross-over rate between groups Ongoing EAST trial (Early Treatment of AF for Stroke Prevention Trial)Hence, the primary treatment goal of CA still remains achievement of symptomatic rather than prognostic improvement, until randomized trials prove beneficial effects on the outcome of stroke or mortality
Packer DL, CABANA trial, JAMA 2019, 321(13);1261-74Kirchhof P, EAST trial- rationale and design, AHJ 2013;166:442-8